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Professional Guidelines: Contrarian Views

Part 2
By Sheila Kirk, M.D.
Part One | Part Two

Several views that I hold may fly directly in the face of many of my professional colleagues. I have stated them often in publications and seminars in the past. Permit me to say it all again. I believe there is a place for orchiectomy (castration) in selected males who want to feminize even if they never move to genital reassignment.

I believe as well, that FTMs, understanding fully what they are doing, can have top surgery and hysterectomies even if they never envision genital reassignment.

I also believe that there is room to consider a selected number of transgendered male and female individuals for contrahormonal therapy even though they may never elect to have surgery or even to live in a full time role.

In a paper recently given at the Harry Benjamin convention in Vancouver, I defended this view. But I also continue to emphasize what I feel are very, very important considerations for those treatments. For one, counseling is necessary to sort out the reasons and ramifications of such treatment. Having the testes removed or rendering either the testes or ovaries inactive by contrahormonal therapy is a most serious step. It's not a casual decision. Hence, a relatively short psychologic evaluation is important.

Even low dose medication has impact upon human physiology and anatomy. Because of the changes that take place, medical evaluation and ongoing monitoring is essential--even with low dose preparations (and that includes natural occurring substances.) Many reject these considerations and use medication without knowledge and direction. I think that's a mistake. It's true, there are problems with identifying professionals to accomplish these goals. Not enough mental health care professionals understand the need and importance to some of low dose therapy. Even fewer physicians and surgeons understand that many transgendered may need only a little for a limited access to a contragender existence. Keep in mind, hormone use without psychologic evaluation and medical evaluation can be potentially dangerous. The counseling need not be lengthy. The medical evaluation need not be profound. But all of it is necessary.

When individuals begin the process to live in a full time role, or to eventually have surgery, they should be encouraged and permitted to take some preliminary steps.

For the FTM, top surgery should be considered strongly. Without it, both psychologic and social implications existt. To be rid of a distinct mark of femaleness (the breasts) fortifies the spirit and adds to the authenticity of the FTM person. There is room to consider this even before Androgen therapy and certainly once it has been started. For the MTF, Electrolysis and hormone treatment begun before an entry into the RLE seems to me most important and necessary. To cast an individual into social situations, and especially into the workplace, before such steps as these are at least initiated is cruel and needless. As I have already stated, some hormone use is permissible in that group of individuals who do not intend surgery or full transition. Then why delay hormones until after the individual steps out into the world in the RLE? Hormone therapy for 3-6 months before the RLE does carry with it changes; we've already admitted to this. But if the individual retreats or delays before or during the RLE, the changes may not be that firmly established to be concerned with particularly for the MTF. The FTM could develop some changes difficult or impossible to alter in a six month span (i.e. voice changes.) But the fact remains; hormones will help greatly an individual's entry into the contragender life. Emotionally and to some degree physically. This is a very proper step not only to allow but to encourage.

The Real Life Experience

There is another very important area to consider; "The Real Life Experience." In a word ...it is very necessary! Difficult, yes! Challenging, yes! Sometimes destructive, yes! Sometimes uplifting and supportive, yes! All of this and more. When one presents their gender identification to the world, they must do it with conviction, with courage and with pride. Will things happen? Indeed they will. But if you are proud of yourself--of your spirit, of the conviction of who you are--you will survive and in fact thrive--in spite of bias and rejection and even financial reversal. That in fact is why you've had counseling to prepare you for this time and life thereafter.

This brings me to the last of my deeply held views. Your counselor/therapist is not just a letter writer, not just a gate you pass through, not just someone you might try to fool!

This person must challenge you, make you think, make you work, make you solve! After that period of obstructing you--that mental health care professional should help to educate you--prepare you, give you insight into what you need to be successful in your new life. They must teach you that its not all dresses, breasts, cigars and a bulge in your pants. It's learning all the attributes, all the values, all the nuances of the gender one now enters and will exist in most probably for all times. To minimize the position of the mental health care provider is a mistake and so many have been known to flaunt it, deny and ignore the value of this professional, rushing to alter the body with medication and surgery. But who will know what is between your legs unless you show them? It's what is in your mind and heart and then in your words and behavior that really counts.

This sounds like preaching and I don't intend that. But I do want you to know what I think are some of the things that professionals and community members should be considering as they work together on such a journey.


Sheila Kirk, M.D. is a board-certified obstetrician/gynecologist specializing in transgender medicine and in private practice in Pittsburgh, PA. She is a board member of the Harry Benjamin International Gender Dysphoria Association. She is the author of several books including "Masculinizing Hormonal Therapy For The Transgendered" and "Medical, Legal and Workplace Issues For the Transsexual" Dr. Kirk can be contacted by phone Tues/Thurs 10A-5P EST (412) 781-1092, 24 hour fax: (412) 781-1096, by post: P.O. Box 38114, Blawnox, PA 15238 or by e-mail: SheilaKirk@aol.com



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